| NPI | 1104162379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301015402) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301015402) |
| Enumeration Date | 2012-12-17 |
| Last Update Date | 2025-07-23 |